APPEARANCES CAN BE DECEIVING: BLUNT HEPATIC INJURY WITH COMPLETELY INTRAHEPATIC SEVERE DUCTAL INJURY

Objectives: Blunt hepatic injury is not only a potentially life-threatening injury but also poses a significant risk for subsequent biliary complications. The incidence of biliary ductal injuries after blunt liver trauma are low but are associated with high morbidity. We present the case of a 38-year-old female who presented as a high-speed single motor vehicle collision with rollover. She was hypotensive on presentation with a positive Focused Assessment with Sonography for Trauma (FAST) exam and taken for a damage control laparotomy which demonstrated two small liver lacerations, one at the caudate lobe and one near the gallbladder fossa. These were easily controlled with electrocautery and packing. Post operative computerized tomography (CT) scans revealed high grade liver laceration without evidence of active contrast extravasation, right rib fractures (ribs 1-3, 11), left rib fractures (1-12), and bilateral pulmonary contusions. She also had sustained fractures of C6-7 spine processes, left T1-2 transverse processes, compression deformities of T12, and left L1-4 transverse processes.
After the damage control laparotomy, the patient developed significant hyperbilirubinemia and transaminitis (total bilirubin 18.6 mg/dL, indirect bilirubin 3.6 mg/dL, direct bilirubin 14.7 mg/dL, alanine transaminase 128 U/L, aspartate transaminase 242 U/L, and alkaline phosphatase 177 U/L), concerning for intrahepatic bile duct injury. We expected to find a significant biliary or hepatic injury on repeat laparotomy, but no bile staining or biliary injury was found. Post operative magnetic resonance cholangiopancreatography (MRCP) was performed and non-diagnostic but concerning for an intrahepatic right hepatic ductal injury. Endoscopic retrograde cholangiopancreatography (ERCP) was performed, and blunt obliteration of the natural biliary tree at the level of the right hepatic duct just distal to the bifurcation of left and right ducts was found. This was subsequently stented across and a sphincterotomy was performed. Post procedure her hyperbilirubinemia resolved with plans for hepatic stent removal/exchange in 6-8 weeks. The patient’s recovery was uneventful and eventually discharged home without complication.
We present this case to demonstrate the importance of a multidisciplinary approach to blunt hepatic injury and that significant injury may not be externally visible, but a high index of suspicion should be maintained.

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